Patient safety problems exist throughout the NHS, as in all large complex health care systems in ...
- Led by a joint team from NHS Bolton and Royal Bolton Hospital NHS Foundation Trust.
- Focus was on improving the handover of information about patients moving through different stages of care and treatment.
- The team used a range of tools to identify areas of potential harm and introduced changes to ensure information flow was timely and accurate.
- Ran from October 2008 until the end of 2013.
A joint team from NHS Bolton and Royal Bolton Hospital NHS Foundation Trust worked on a project to improve the handover of information about patients moving through different stages of care. The project aimed to reduce harm caused by the transfer of clinical information in the urgent care pathway by 50%.
The team used tools to identify areas of potential harm, such as the ‘global trigger tool’, which highlighted areas of harm linked to readmissions. They analysed issues using techniques such as failure modes and effects analysis, process mapping and expert review.
The team designed a new standard handover process based on the SBAR model (situation, background, assessment, and recommendation). Other tools included a discharge handout for patients, a new blood investigation guide and regular evaluation of information handovers.
Learning points from phase one
- A culture of transparency and information sharing is required across teams, services and organisations.
- Cross-organisational working takes time and effort but is invaluable.
- It is not just a project. Safety and quality must be embedded goals in all our work.
- Motivated staff members with a passion for safety are crucial in developing safe systems. Managerial support is also vital to be able to implement change effectively.
- Existing data were often not fit for purpose and a more qualitative approach was needed.
- New tools were initially treated with suspicion, however many initial assumptions about causes of harm were incorrect. Tools such as the global trigger tool showed the true areas of concern not previously identified.